Periaortic Hematoma Research Articles

Aortic Intramural Hematoma Mimicking Acute Coronary Syndrome

Type A Aortic intramural haematoma (IMH), a variant form of classic aortic dissection, has been accepted as an increasingly recognised and potentially fatal entity of acute aortic syndrome.It is a very dangerous, fatal, and emergency condition. It is very important to recognize the symptoms of acute aortic syndrome related to appropriate management Case Illustration A 52 year old man patient suffered from chest pain with moderate intensity while he was working at home. It was sharp , tear-like sensation, in the middle of the chest radiated to the back, accompanied with cold sweating, and did not relieve by rest. Because of this condition he brought to hospital. From examination at Emergency room, he had cardiomegaly, aortic dilatation. From the Electrocardiography an st elevation at V1-V2 and T inverted V4-V6 precordial lead,I aVL extremities lead and slightly elevated cardiac enzymes with risk factors for active smoking and uncontrolled hypertension. Initially he was suspected of having acute coronary syndrome with differential diagnose acute aortic syndrome. To exclude the diagnose he had underwent cardiac catheterization, the cardiologist in charge suspicious this patient with aortic dissection because of trapping contrast durante procedure and coronary minor disease. For a better diagnosis, transtransthoracic echocardiography and Aortic Computed Tomography angiography was performed on the patient which confirmed the evidence of dissection. After being diagnosed, we treat the patient as an acute aortic syndrome and we stabilize the patient's condition. The patient was planned for cardiac surgery Discussion Acute aortic syndrome, which includes Acute Aortic Dissection, Intramural Hematoma and penetrating aortic ulcer, is difficult to diagnosed. Aortic intramural hematoma, which is one of the acute aortic syndromes, is characterized by the presence of a hematoma in the medial layer of the aortic wall without the appearance of an intimal tear. The incidence of intramural hematoma differs slightly from that of aortic dissection syndrome. Patients with intramural hematomas often occur in older patients, more often with aortic aneurysms The patient receive treatment aggressively to control blood pressure by administering a non-dihydropyridine calcium channel blocker intravenously and then beta blocker, angiotensin II receptor blockers, was also needed. Acute aortic syndrome, where an intramural aortic hematoma can present with varying symptoms of varying severity, which can lead to misdiagnosis and delay in cases of life-threatening disease. In the case of our patient, who had strong cardiac risk factors, His initial presentation described an acute myocardial infarction; the diagnosis was made after CT scan was performed and the patient remained stable Conclussion Complaints of chest pain due to symptoms of acute aortic syndrome are very important to be recognized immediately because they need proper management. Complaints in this syndrome have similarities with complaints in acute coronary syndrome, pulmonary embolism and others. Patients with aortic intramural hematoma are at high risk for developing periaortic hematoma and hemorrhagic pericardial effusion. In patients with an intramural aortic hematoma, Stanford A, the most appropriate management is surgical technique. Initial management of blood pressure control, heart rate and anti-pain can be given. In this case, the choice of a combination of surgery with endovascular may be a logical choice of therapy

Imaging case series of melioidosis: the great masquerader

BackgroundMelioidosis is an infectious disease caused by Gram-negative bacterium Burkholderia pseudomallei. It is endemic to Southeast Asia. Inhalation, inoculation and ingestion are major routes of transmission. Increased risk of infection is seen in patients with diabetes, alcoholism, chronic renal and liver failure and malignancy. The aim of the present case series is to describe the varied imaging manifestations of melioidosis.Case presentationThis is a retrospective review of imaging findings in eight patients with culture-proven B. pseudomallei infections diagnosed in our institute from September 2019 to September 2021. A total of eight culture-proven melioidosis cases were reported from our institute. All of them had multiorgan involvement and predisposing conditions or risk factors, most common being diabetes mellitus and alcoholism. Lung was the most common organ involved showing nodules and consolidations followed by liver and spleen demonstrating multiple ‘honeycomb’-like abscesses. Musculoskeletal manifestations included osteomyelitis and intramuscular abscess. Cerebral abscess, cerebral infarcts, prostatic abscess, abdominal aortic mycotic aneurysm with periaortic hematoma and splenic vein thrombosis with splenic infarcts were a few other manifestations.ConclusionsMelioidosis is a great mimicker with acute, subacute or chronic clinical course involving multiple organs and resembling other common infections. Hence, it should be considered as a possible etiological agent when evaluating patients with risk factors and multiorgan involvement.

Abstract 10768: Double Whammy: An Unusual Case of Mycotic Abdominal Aortic Aneurysm in a Bacteremic Patient - Case Report

Introduction: Ruptured mycotic aortic aneurysm is a relatively rare, life-threatening disease, which is associated with remarkable mortality. In East Asia, mortality caused by this disease is high and it is commonly caused by Salmonella species. Majority of cases of mycotic aneurysms caused by Salmonella were in the abdominal aorta wherein most of them presented with chills and fever while some presented with diarrhea from 2 days to 1 month before the aneurysm was diagnosed. Patients who present with diarrhea and abdominal pain are likely to be missed. It is therefore important that mycotic abdominal aneurysm be recognized early, and prompt treatment be initiated. Case: A 78-year-old American male, Philippine immigrant with history of ischemic stroke and chronic smoking presented with diarrhea and severe abdominal pain. Complete blood count showed leukocytosis with neutrophilic predominance. A computed tomography scan of whole abdomen exhibited a fusiform aneurysm of the infrarenal abdominal aorta with large periaortic hematoma indicating prior rupture. Open abdominal aortic aneurysm repair was successfully done and intravenous Meropenem and Ciprofloxacin were given. Blood, urine, thrombus, and aortic plaque cultures were obtained and all revealed Salmonella specie with same antibiogram. Intravenous Meropenem and Ciprofloxacin was transitioned to intravenous Ceftriaxone and was continued for 6 weeks post-operatively. Conclusion: Mycotic abdominal aortic aneurysm can be diagnosed with the combination of clinical symptoms, laboratory, radiological findings, and intraoperative findings. However, vague and non-specific symptoms do not rule out the diagnosis. High index of suspicion and low threshold for CT imaging is necessary in any patient age >60 years who present with abdominal pain and with previous history of gastroenteritis. Prompt initiation of antibiotic therapy and surgical intervention are the treatment of choice.

Progressive dysphagia and dyspnea after thoracic endovascular aortic repair due to a rare cause of type II endoleak

A 34-year-old man was admitted to a local hospital with progressively worsening dysphagia and dyspnea 3 weeks after thoracic endovascular aortic repair (TEVAR) of acute type B aortic dissection. Computed tomography angiography (CTA) showed a huge periaortic hematoma (77 mm × 63 mm, asterisk) resulting in severe compression of the esophagus and left trachea (A). The patient was rapidly transferred to our unit, and physical examination indicated diminished left chest breath sound. Although type I or III endoleak (red arrowhead) was initially suspected (B; Supplementary Video 1, online only), such diagnoses were excluded by the intraluminal aortography (Supplementary Video 2, online only).

Aortic Healing Appears to Occur Rapidly after Successful Endovascular Sealing of Blunt Thoracic Aortic Injury

The traumatic nature of blunt thoracic aortic injury (BTAI) would suggest that healing of the aorta would occur once the injured area is shielded from aortic pressure. This would be in contrast to degenerative aortic diseases which often continue to degenerate despite coverage. We hypothesize that after successful thoracic aortic endografting (TEVAR) that the aorta rapidly heals itself leaving minimal to no trace of the residual injury. BTAI that were successfully covered with TEVAR from 2006 to 2019 were collected. Those with failed sealing or a lack of follow-up scans were excluded. Centerline aortic diameters were measured at healthy aorta 1cm above (D1) and below the injury (D3) and at the widest point of injury (D2) on preoperative and initial postoperative computed tomography (CT) scans. Postoperative CTs were examined for residual signs of aortic injury including residual periaortic hematoma, persistent thrombosed pseudoaneurysm, or thickened aortic wall. Diameter changes in the healthy and injured aortic segments were compared pre and post TEVAR. Aortic diameter changes were analyzed with the Student's t-test. Twenty four patients were identified with sealed BTAI. The mean graft diameter was 24.2±3.2mm with oversizing of 10.74±6.1 % at D1 and 19.52±10.22 % at D3. Postoperative CTs occurred at 61.25±123.6days with one outlier at 602days. Injured aortic segments (D2) had significantly larger diameters compared to D1 (28.94±5.08mm vs. 22.14±3.08mm, P<0.001). After TEVAR, 23/24 (95.8%) had no residual radiographic evidence of aortic injury by 2months. One patient had a persistent thrombosed pseudoaneurysm likely due to more than 50% disruption of the aortic wall. Post TEVAR, there was a significant diameter reduction at D2 by 13.8% (29.10±5.27mm vs. 24.8±4.2mm, P<0.001) which was within 2.45% of the mean stent graft diameter. The healthy aorta dilated to accommodate the graft by 9% at D1 (21.9±3.0 vs. 23.7±2.5mm, P<0.001) and 17% at D3 (20.6±3.4mm vs. 23.6±3.2mm, P<0.001). TEVAR promotes rapid aortic healing in BTAI with no evidence of residual aortic injury suggesting that a long-term seal is not necessary. The healthy aorta dilates to the stent graft size, as expected, whereas the injured aortic segment heals around the stent graft and assumes its diameter as well. Massive disruption of the aortic wall may preclude early healing.

Outcomes of operative and nonoperative management of blunt thoracic aortic injury

ObjectiveAlthough the current guidelines for the management of blunt traumatic aortic injury (BTAI) have recommended intervention for grade 2 injuries or higher, a national trend has occurred for aggressive endovascular treatment of low-grade BTAIs. Little is known about the natural history of grade 1 and 2 injuries treated nonoperatively. We hypothesized that most of these low-grade injuries would remain stable with nonoperative management. MethodsWe performed a review of BTAIs at a large referral level 1 trauma center from 2004 to 2020. The injuries were graded using a standard 1 to 4 scale. The outcomes of the nonoperative and thoracic endovascular aortic repair (TEVAR) management strategies were compared, including post-trauma morbidity, mortality, reinterventions, and lesion stability. ResultsA total of 176 patients with BTAIs and sufficient imaging studies and follow-up data available were identified during the study period, including 36 with grade 1, 24 with grade 2, 115 with grade 3, and 1 with a grade 4 injury. Of these 176 patients, 112 had undergone TEVAR and 64 had been treated nonoperatively. Most of the patients (90.2%) who had undergone TEVAR had had grade 3 injuries. Nonoperative management was performed for 97.2% of the grade 1 injuries and 62.5% of the grade 2 injuries. Endovascular reintervention after TEVAR was rare (2.7%). The rates of post-trauma morbidity within 30 days (stroke, 3.6% vs 3.1%; myocardial infarction/arrhythmia, 8.9% vs 1.6%; respiratory failure, 31.2% vs 28.1%; acute kidney injury, 9.8% vs 12.5%; urinary tract infection, 2.7% vs 4.8%; gastrointestinal bleeding, 3.6% vs 0.0%; pulmonary embolism, 10.9% vs 4.5%) and 1-year mortality after discharge (1.8% vs 3.1%) were comparable between the operative and nonoperative groups. The median follow-up was 1501 days (interquartile range [IQR], 475.6-2804 days) for the TEVAR group and 1170.5 days (IQR, 317-2173 days) for the nonoperative group. No lesion progression had occurred in the patients with low-grade (grade 1-2) injuries managed nonoperatively. Resolution of grade 1 and 2 injury had occurred in 20% of the patients at 30 days, which had improved to 44% at long-term follow-up. Fourteen patients with grade 3 injuries (12.2% of the grade 3 injuries in our series) were also observed and did not require future intervention. These patients had generally had smaller pseudoaneurysms with minimal periaortic hematoma. None of these 14 patients had experienced progression or rupture during follow-up (median, 454.5 days; IQR, 81-1199 days) using computed tomography. ConclusionsNonoperative management of low-grade BTAIs did not result in long-term aortic complications or the need for reintervention. We found that grade 3 injuries with smaller pseudoaneurysms and minimal periaortic hematoma can be safely observed if the patients can be appropriately followed up. Thus, the indications for treatment of select grade 3 injuries merit further consideration.

Эндоваскулярная имплантация стент-графта в аорту в условиях гибридной операционной при помощи современной мобильной рентгеновской С-дуги: клинический случай

Thanks to the development of modern mobile imaging devices, the treatment of such a serious pa-thology as aortic aneurysm has become more accessible. Thoracic aortic aneurysms are the most common pathology of the thoracic aorta. It occurs with increasing frequency (10 cases per 100,000 people per year). The most common cause of the disease is atherosclerosis. To date, the treat-ment of this serious pathology has become more accessible due to the development of modern mobile imaging devices. As compared to stationary devices, the portable devices for angiography of the latest generation are movable and can be moved from site to site quickly and easily they produce high quality angiograms, the system can be accessible to any health-care institutions. The paper presents the first in Russia successful case of endoprosthetics of the thoracic aorta using mobile C-arm RFD Ziehm Vision. A 75-year-old man was found to have a symptomatic thoracic aortic aneurysm up to 67 mm in diameter, complicated by intramural (1.2 cm thick) and periaortic hematomas and compression atelectasis of the lower lobe of the left lung. The patient underwent prosthetics of the root, ascending part and arch of the aorta with a 30x8 (mm) synthetic prosthesis and intraoperative stenting of the descending thoracic aorta on a mobile C-arm. Our clinical expe-rience shows that difficult hybrid interventions can be successful if they are carried out in a surgical operating room with the use of a high-power C-arm with angiography function. This approach al-lows specialists to obtain image of required quality, with low exposure of a patient to ionizing radia-tion. The method can be used in the absence of stationary angiographs.

Emergency Endovascular Total Arch Exclusion With an Off-the-Shelf Bimodular Device.

A patient with a history of surgery for type A acute aortic dissection was readmitted for aortic arch and descending aortic dissection with rupture at the isthmus and periaortic hematoma. Due to the high surgical risk, the aortic team chose an endovascular approach, and the patient successfully underwent emergency total arch exclusion with an off-the-shelf, bimodular, single-branch device. The main module was deployed in the aortic arch and in the brachiocephalic trunk, and the second module was deployed in the ascending aorta. Despite the good perioperative outcome with no cerebrovascular events, the patient died 20 days later because of sudden iliac rupture.

Comparison of the Bifurcated Graft Reconstruction and Aortic Stump Closure in Open Surgical Conversion After Endovascular Aneurysm Repair

The optimal management of the aortic stump in open surgical conversion (OSC) after Abdominal aortic aneurysm (AAA) endovascular aneurysm repair (EVAR) is debated. Therefore, we aimed to compare the efficacies and safety between the bifurcated prosthetic vascular graft in situ stump reconstruction (p-graft ISSR) and aortic stump closure (ASC) in OSC. We analyzed 973 elective AAA patients admitted from January 01, 2001 to December 31, 2020, at the First Affiliated Hospital of Sun Yat-sen University. We conducted a statistical analysis of the clinical characteristics, procedural data, as well as outcomes and technique considerations of aortic stump management in OSC patients. A total of 24 male patients had OSC after EVAR. The rate of stent graft infection was 54.17% before OSC. Eleven patients underwent ASC, and 13 patients were treated with p-graft ISSR. The major complication after OSC was aortic stump bleeding (total incidence was 37.50%) (1 patient with a periaortic hematoma and 8 patients with a stump blowout). The total incidences of stump blowout between the patients with ASC and those with p-graft ISSR were significantly different (45.45% vs. 23.08%, P < 0.05). The total perioperative mortality was 25.00% (6 patients with stump blowouts). The perioperative survival rates between these 2 aortic stump management approaches were 72.72% and 76.92% (ASC vs. p-graft ISSR, P < 0.05). In total, 18 patients were followed up (3-180 months). There were 3 aorta-related deaths during the late follow-up period (including both of the 2 stump-blowout-related deaths just treated with ASC). If the condition of the aorta and peri-aortic tissue are suitable for a prosthetic graft bypass, the p-graft ISSR is highly recommended for OSC patients after EVAR.

Infected peri-aortic hematoma diagnosed on F-18 FDG PET/CT imaging

Infected peri-aortic hematoma diagnosed on F-18 FDG PET/CT imaging

Endovascular treatment of traumatic azygous vein injuries: a case report

BackgroundManagement of thoracic vascular injury predominantly focuses on the aorta and its tributaries while reports of venous injury are less frequent. Although rare, traumatic azygous vein injuries are associated with high mortality. Prompt treatment is required and has traditionally been open surgery. We present a case of an endovascular repair of an azygous vein injury.Case presentationA female patient presented to our trauma center following ejection after a motor vehicle collision (MVC). CT imaging workup revealed mediastinal and periaortic hematoma with active contrast extravasation adjacent to the azygos vein. She was referred to interventional radiology for vascular evaluation and potential endovascular intervention. The patient met criteria for class III hypovolemic shock upon arrival in the endovascular suite. Aortography demonstrated no arterial injury. Venography revealed a pseudoaneurysm on the superior aspect of the azygos arch and contrast extravasation from the inferior margin of the azygous arch. A stent-graft was deployed and post-deployment venogram showed no extravasation and successful exclusion of the injuries. The patient did not have further signs of bleeding. She left the interventional suite with improved vital signs, yet her condition remained guarded. Follow-up CT chest confirmed continued patency of the stent-graft at 8 days and 2 years post-procedure.ConclusionHistorically, azygos vein injuries are a rare occurrence and managed with open surgery. Swift management is necessary to prevent the increased morbidity and mortality associated with azygous vein injury, particularly in polytrauma patients such as the one presented here. We believe endovascular stent-graft treatment offers an innovative alternative to the current standard of operative management of azygos vein injury.

Sex-Based Aortic Dissection Outcomes From the International Registry of Acute Aortic Dissection

BackgroundWorse outcomes have been reported for women with type A acute aortic dissection (TAAD). We sought to determine sex-specific operative approaches and outcomes for TAAD in the current era. MethodsThe Interventional Cohort (IVC) of the International Registry of Acute Aortic Dissection (IRAD) database was queried to explore sex differences in presentation, operative approach, and outcomes. Multivariable logistic regression was performed to identify adjusted outcomes in relation to sex. ResultsWomen constituted approximately one-third (34.3%) of the 2823 patients and were significantly older than men (65.4 vs 58.6 years, P < .001). Women were more likely to present with intramural hematoma, periaortic hematoma, or complete or partial false lumen thrombosis (all P < .05) and more commonly had hypotension or coma (P = .001). Men underwent a greater proportion of Bentall, complete arch, and elephant trunk procedures (all P < .01). In-hospital mortality during the study period was higher in women (16.7% vs 13.8%, P = .039). After adjustment, female sex trended towards higher in-hospital mortality overall (odds ratio, 1.40; P = .053) but not in the last decade of enrollment (odds ratio, 0.93; P = .807). Five-year mortality and reintervention rates were not significantly different between the sexes. ConclusionsIn-hospital mortality remains higher among women with TAAD but demonstrates improvement in the last decade. Significant differences in presentation were noted in women, including older age, distinct imaging findings, and greater evidence of malperfusion. Although no distinctions in 5-year mortality or reintervention were observed, a tailored surgical approach should be considered to reduce sex disparities in early mortality rates for TAAD.

Sex Differences of Clinical Presentation and Outcomes in Propensity-Matched Patients with Acute Type A Aortic Dissection.

To assess sex differences of clinical presentation and outcomes in propensity-matched patients with acute type A aortic dissection (AAAD). We collected the clinical data of patients with AAAD from a single heart center between January 2009 and July 2014. After propensity score matching, we compared differences in clinical presentation and outcomes of patients with AAAD between men and women. There were 590 patients (295 men and 295 women) with AAAD through propensity matching on demographics and patients' history. We found that the presentation and diagnosis of AAAD often were more delayed in women. Severe signs of congestive heart failure (9.8% vs. 5.1%, P = 0.017), cardiac tamponade/shock (9.1% vs. 4.1%, P < 0.001), and periaortic hematoma (26.4% vs. 21.7%, P < 0.001) were more commonly presented in women. Surgery was more commonly performed in men than in women (95.4% (281/295) vs. 91.5% (270/295), P = 0.045), indicating the association of sex with surgical decision. To investigate the association of sex with outcomes after surgery, patients who underwent surgical treatment were re-matched (262 men and 262 women) by propensity score. Women suffered from greater in-hospital mortality than men (8.4% vs. 3.4%, P < 0.001). Postoperative complications of congestive heart failure (9.1% vs. 3.8%, P < 0.001), visceral ischemia (6.8% vs. 1.1%, P < 0.001), and limb ischemia (7.6% vs. 1.5%, P < 0.001) were more frequent in women. For women, prolonged operative time may increase in-hospital mortality, especially after 12 hours from the start of surgery (30.0% vs. 14.3%, P < 0.001). Kaplan-Meier survival analysis indicated worse late outcomes in women in the matched surgery group (log-rank P = 0.012). Our analysis provides new insights into sex differences in clinical presentation and outcomes of AAAD.

Man with trauma following motorcycle crash.

A 56-year-old male presented to the emergency department (ED) following a frontal impact motorcycle accident. The patient was pale with persistent hypotension, tachypnea, and tachycardia along with bilateral lower limbs paralysis and a complete loss of sphincter functions. Patient was intubated, and transesophageal echocardiography performed by attending emergency physician at ED critical care bayshowed the transverse and longitudinal view of the descending aorta with hypoechoic, well-defined, crescent-shaped thickening of anterior aortic wall suggestive of intramural hematoma (Figures 1, 2; Supporting Information Videos S1 and S2). Computed tomography (CT) showed fracture T11 vertebra, intramural hematoma, and peri-aortic hematoma along the arch of the aorta extending down to upper abdominal aorta at the level of T12 (Figure 3). Traumatic thoracolumbar spine fracture with a concomitant blunt aortic injury is uncommon (1.4%) but potentially fatal.1 Most fractures associated with blunt traumatic aortic injury occurred at the level of T11–L2 vertebra (62%).1 ED transesophageal echocardiography is a potential new imaging adjunct in resuscitation.2-4 Even though the surface ultrasound has become an important bedside imaging tool in initial management of trauma patients in ED, its limitations include poor evaluation of vascular pathologies (ie, BTAI).5 The role of ED transesophageal echocardiography for the early detection of BTAI in hemodynamically unstable trauma patient was reported by Osman et al.6 The patient was managed conservatively and was discharged from spinal intensive care unit after day 10. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

Medical and surgical management of acute type B aortic intramural hematoma.

Type B acute aortic dissection (AAD) and intramural hematoma (IMH) can both present as potentially catastrophic lesions of the descending aorta. IMH is distinguished from AAD by the absence of an intimal tear and flap. With short-term outcomes being similar to type B AAD, IMH is treated identically to AAD in the corresponding segment of the aorta. While all patients with any acute aortic syndrome of the descending aorta receive prompt anti-impulse therapy, thoracic endovascular aortic repair (TEVAR) is reserved for patients presenting with certain complications, namely malperfusion, rupture, or periaortic hematoma. Technical aspects of TEVAR for IMH include maximal endograft oversizing of 10% with 20 mm landing zones of the healthy aorta, revascularization of the left subclavian artery when covered, use of cerebrospinal fluid drainage with extensive coverage, and restoration of branch vessel perfusion. With respect to disease evolution, IMH may progress to classic AD, frank rupture, or aneurysmal dilation; yet, IMH may also regress and be completely resorbed. However, since the natural history of IMH is unpredictable, TEVAR is being used more aggressively to improve long-term survival, rates of secondary reintervention, and positive aortic remodeling. Much remains unknown for acute type B IMH, including the use of prophylactic TEVAR for stable uncomplicated presentations, as well as the optimal timing of intervention and certain technical aspects of TEVAR. As such, IMH remains a diagnostic and therapeutic challenge for cardiovascular surgeons.

Current trends in the management of acute type A aortic intramural hematoma

Within the spectrum of acute aortic syndromes, intramural hematoma (IMH) is a distinct lesion that is characterized by crescentic or circumferential thickening of the aortic wall in the absence of an intimal defect. The reported incidence of IMH among all type A acute aortic syndromes ranges from 3.5% to 28.3%. As compared with acute aortic dissection, IMH is a disease of the elderly, and it tends to have reduced rates of malperfusion syndromes, aortic insufficiency, and root dilation, yet also tends to have increased rates of pericardial effusion, cardiac tamponade, and periaortic hematoma. With respect to natural history, IMH may progress to classic dissection, frank rupture, or aneurysmal dilation; yet, IMH may also regress and be completely resorbed. However, studies disagree over the rates of progression or regression; as such, few studies agree on the short-term and long-term prognosis associated with IMH. American and European guidelines advocate emergent surgery for all acutely presenting type A IMH. At a minimum, supracoronary replacement of the aorta with hemiarch reconstruction is the preferred extent of operative repair to reduce rates of long-term reintervention for disease progression. However, valve and/or root procedures may be necessary proximally, while total arch reconstruction or hybrid procedures for the descending aorta may be necessary distally. Much remains unknown for IMH, including the ideal extent of aortic repair, risk-stratification for elderly patients, and the optimal treatment paradigm for stable, uncomplicated IMH. As such, IMH remains a diagnostic and therapeutic challenge for the cardiovascular surgeon.

Thoracic Endovascular Aortic Repair for Type B Aortic Dissection Associated with Retrograde Type A Intramural Hematoma

PurposeTo evaluate feasibility and efficacy of thoracic endovascular aortic repair (TEVAR) for type B aortic dissection (TBAD) associated with retrograde type A intramural hematoma (IMH). Materials and MethodsFrom April 2013 to January 2017, 15 consecutive patients with TBAD associated with retrograde type A IMH who underwent TEVAR were reviewed retrospectively. There was no cardiac tamponade, aortic regurgitation, involvement of coronary artery, or sign of cerebral ischemia in these patients. Enhanced CT was used in 4 patients to diagnose malperfusion of abdominal visceral arteries or lower extremity artery and underwent emergent TEVAR. For the remaining 11 patients, repeated enhanced CT after initial medical treatment within 24 hours from onset of pain showed expansion of IMH in 8 patients or presence of periaortic hematoma in 3 patients. Delayed TEVAR was scheduled for these cases. ResultsSuccessful deployment of the stent graft was achieved in all patients. There were no severe postoperative complications, such as retrograde type A aortic dissection or aortic rupture. Sudden death occurred in 1 patient 3 months after the procedure. Thrombosis of the false lumen, shrinkage of the diameter of the aorta, and complete absorption of the IMH were observed in the remaining patients at a mean follow-up of 19.8 months ± 6.57. ConclusionsTEVAR for treatment of TBAD with retrograde type A IMH is feasible and effective. It represents a treatment option for patients with TBAD associated with type A IMH with a proximal entry tear located in the descending aorta.

P692 Curious Bentall procedure complications, not always found in the immediate postoperative period

Abstract Ascending aorta aneurisms are often diagnosed in patients around 60-70 years old with prior history of hypertension or smoking, or in younger patients with connective tissue illnesses, such as Marfan Syndrome (MS), or bicuspide aortic valve (BAV). In patients with MS an aneurysm of the aortic root, ascending aorta or acute dissection are the most frequent reasons of death, that is why an aggressive surgical approach is recommended, by repairing or replacing the diseased aortic root. Prophylactic aortic root surgery is an effective procedure in preventing acute dissection and rupture with excellent long-term outcomes as published in the literature, being the Bentall procedure usually the treatment of choice. However, the implantation of a mechanic aortic prosthesis makes permanent oral anticoagulation necessary with elevated haemorragic risk. We present two peculiar cases of Bentall procedure with differentes indications, different scenarios but similar outcomes. - Case A: A 75-year-old female with MS who underwent Bentall surgery in 1988 due to a severe AR, stable and asymptomatic since then. In a routine check-up in November 2017, a dilatation of 65mm in her native ascending aorta was detected on a computed tomography scan (CT), visualizing a half-moon shaped space between the ascending aorta and the aortic tube of 21x46mm and a leak from de aorto-ostial union, being possible to confirm with the TEE its origin in the left coronary ostium, which was also dilated (10mm), due to a dehiscence in the aortic tube suture on that level. - Case B: A 43-year-old male who underwent Bentall surgery in 2014 due to a severe AR and aortic root aneurysm that in January 2017 was admitted to our hospital due to chest pain with no other symptoms associated. As part of the study and TTE, TEE and CT were performed in which a periaortic haematoma from de aortic root to the beginning of the aortic arch was found, visualizing a leak from a 5mm hole in the ostium of the right coronary artery. In addition, the left coronary artery had a severe stenosis (85%) due to the compression of the haematoma on that level. Even though the Bentall procedure has excellent outcomes we discovered unusual either long and short-term complications due to dehiscence of the sutures, causing a huge peri-prosthetic tube haematoma, compressing the left main coronary artery in one of our patients which was the cause of the angina he presented with. We think these images could help the diagnostic process in future cases since these complications are not only found in the immediate postoperative period and should always be in our minds. Abstract P692 Figure.

Predicting in-hospital rupture of type A aortic dissection using Random Forest.

This study is to establish prediction tools for in-hospital rupture of type A aortic dissection (TAAD) patients, to better guide emergency surgical triage and patient counselling. We retrospectively evaluated 1,133 consecutive patients with TAAD from January 2010 to December 2016. The study population was divided into training and testing datasets in a 70:30 ratio for further analysis using Random Forest. The Random Forest classification model was developed with the training dataset and 16 variables were confirmed as 'important': age, BMI, gender, syncope, lower limb numbness/pain, acute phase of the TAAD, BP >160 mmHg at admission; acute liver dysfunction, WBC >15×109/L, aortic size, aortic height index (AHI), periaortic hematoma, pleural effusion, brachiocephalic artery involvement, renal artery involvement, and hemopericardium. Validation of the model showed good discrimination with an AUC, sensitivity, specificity, positive predictive value and negative predictive value of 0.994, 1.000, 0.987, 0.998 and 1.000, respectively, in the training dataset, and 0.752, 0.990, 0.514, 0.945 and 0.857, respectively, in the testing dataset. An easy-to-use tool to predict in-hospital rupture for TAAD patients was developed and validated (http://47.107.228.109/). Periaortic hematoma is the strongest predictor. Simple clinical information such as syncope can be very useful in in-hospital rupture risk stratification.

Blunt aortic injuries in the new era: radiologic findings and polytrauma risk assessment dictates management strategy.

Blunt aortic injuries (BAI) have historically been considered an indication for emergent surgical intervention. Nevertheless, the observation that the outcome of the concomitant traumatic injuries has a major impact on prognosis and the rise of thoracic endovascular aortic repair (TEVAR) as an effective therapy for BAI have significantly changed in recent years the treatment algorithm of this condition. Our objective was to identify findings associated with the aortic injury which would be the best predictor of prognosis, with the objective of guiding the decision-making process for selecting the optimal timing of aortic repair. We reviewed blunt aortic injuries from 3 Level I Trauma Centers from July 2008 to December 2016. We analyzed overall and BAI-related 30-day mortality in relation to: hemodynamics, timing of treatment, TEVAR vs open repair, and aortic injury grade as defined by the Society for Vascular Surgery. Based on computed tomographic angiography (CT scan) imaging, we selected the radiologic aortic findings most indicative of high mortality risk, which we defined as "Radiographic Severe Injury" (RSI): (1) total/partial aortic transection, (2) active contrast extravasation, or (3) the association of 2 of more of the following: contained contrast extravasation > 10mm, periaortic hematoma, and/or mediastinal hematoma with thickness > 10mm, or significant left pleural effusion. Of a total of 76 consecutive patients, 50 (66%) underwent immediate repair, 24 (31%) delayed aortic repair, and 2 (3%) died prior to repair. 58 patients (76%) had TEVAR, while 16 (24%) had open repair. Overall mortality was 18% and BAI-related mortality was 13%. In BAI-related mortalities, 70% of patients had RSI. Patients with high risk of overall mortality had hypotension and tachycardia (SBP < 100, HR ≥ 100), high ISS, and required vasopressors. Factors only associated with BAI-related mortality included RSI. CT scan findings suggestive of RSI are predictive of mortality associated with BAI. Radiologic assessment of the severity of the aortic injury with characterization for the presence of RSI may represent the key factors to determine the optimal timing of treatment of the aortic injury and guide the overall treatment strategy. IV.